Trauma exposure,social functioning,and common mental health disorders in Somali refugee male and female youth: An SEM analysis

Abstract

Background:

Refugee youth often face numerous adversities before and during forced migration. Although experiences vary across settings and subpopulations, common mental disorders are prevalent among refugee youth who are displaced in low- and middle-income countries. It is important to examine how risk factors are intricately linked and contribute to common mental health issues to inform clinical practice and social policy.

Aims:

This study aims to test the pathways from risk factors previously identified as determinants of Somali refugee youth mental health (i.e. trauma exposure, substance use, social functioning, aggression) to symptoms of PTSD, depression, anxiety, and somatic pains.

Method:

We collected survey data in 2013, using snowball sampling to recruit Somali refugee youth (15–35 years old) living in Eastleigh, Kenya. We ran three structural equation models to assess paths from trauma exposure to mental health symptoms, through psychosocial factors including substance use, aggression, and functional impairment. We first conducted this analysis with a mixed-gender sample (N = 305) and then assessed gender differences by running one model for male participants (n = 124) and another for female participants (n = 181).

Results:

In the mixed-gender sample, trauma exposure directly predicted substance use and both directly and indirectly predicted aggression, functional impairment, and mental health symptoms. Substance use directly predicted aggression and functional impairment, and substance use both directly and indirectly predicted mental health symptoms. The split-gender models revealed gender differences, with only functional impairment directly predicting mental health symptoms in the male sample and with many significant direct and indirect pathways in the female sample.

Conclusions:

This study shows the role of trauma exposure, substance use, aggression, and social functioning in determining mental health outcomes among refugee youth and how CMD symptoms are differently manifested across genders in this population.

Keywords

Refugee youth mental health structural equation modeling functional impairment substance use aggression gender difference

Refugee youth comprise the majority of refugee populations globally, including an estimated 30 to 34 million minors below the age of 18 (United Nations High Commissioner for Refugees [UNHCR], 2020a). Given the challenges throughout forced migration, refugee youth are exposed to cumulative and prolonged traumas that can worsen social functioning and health and mental health outcomes (Frounfelker et al., 2020; Newnham et al., 2018; Reed et al., 2012). Although experiences vary across settings and subpopulations (Blackmore et al., 2020; Fazel et al., 2005; Hinton & Lewis-Fernández, 2011), common mental disorders (CMDs), such as depression, anxiety, post-traumatic stress disorder (PTSD), and somatization, are prevalent among refugee youth and particularly those in low- or middle-income countries (LMICs; Frounfelker et al., 2020; Reed et al., 2012). For example, up to 87% of refugee youth in camp settings report trauma-related CMD symptoms (Vossoughi et al., 2018). Precarious living in low-resource settings likely adds multi-layered challenges that exacerbate mental health issues in refugee children and youth (Patel et al., 2008; Scharpf et al., 2020).

Various risk and resilient factors impacting mental health at individual, family, and school and community levels have been identified and explored in previous research (Patel et al., 2008; Pieloch et al., 2016; Roberts & Browne, 2011; Tol et al., 2010). Some of these factors include demographic characteristics (e.g. gender, age, education, socio-economic factors), the type and chronicity of trauma exposure (e.g. cumulative or prolonged trauma vs. acute trauma, complex trauma, recency of trauma events), coping styles and resources, social functioning, and family and community support (de Anstiss & Ziaian, 2010; Giacco et al., 2018; McGregor et al., 2015). Refugee youth, for example, appear to have greater resilience and less mental health susceptibility than older refugees following stress and trauma related to migration (Ahmad et al., 2020; Jensen et al., 2015; Porter & Haslam, 2005). Among others, gender is a significant predictor of CMDs as well as refugee traumas. Numerous studies have shown that women are at higher risk of mental health issues, especially PTSD and depression, than men (Olff et al., 2007; Schubert & Punamäki, 2011; Sherin & Nemeroff, 2011; Young & Chan, 2015). This increased risk is often attributed to the types of trauma events commonly experienced by women (e.g. sexual and gender-based violence), which are likely to occur at a younger age and have more devastating physical and mental health effects on women with stronger perceptions of threat and loss of control due to insufficient social support resources during social conflicts or displacement (Olff et al., 2007; Renner & Salem, 2009). The type and chronicity of refugee trauma experiences are also well-known factors associated with mental health outcomes (Bielas et al., 2016; Reed et al., 2012) along with substance use as self-medication in response to trauma (Ertl et al., 2016; Horyniak et al., 2016; Lockwood & Forbes, 2014; Posselt et al., 2015). Both trauma exposure and malfunctioning coping, such as substance use, have devastating effects on social functioning, which likely exacerbate mental health symptoms in refugee populations (Lockwood & Forbes, 2014; Miró et al., 2020; Norman et al., 2018; Rodriguez et al., 2012).

Mental health among Somali refugee youth

Somali refugee communities have experienced prolonged conflict for decades, since the civil war in 1991, which caused the forced migration and protracted displacement of millions of Somalis (UNHCR, 2020b). Due to the cumulative effects of individual and collective traumas and life challenges faced before and during displacement, high levels of CMDs, substance use, and psychiatric problems have been reported in Somali refugees, including youth (de Jong et al., 2011; Ellis et al., 2010; Feyera et al., 2015; Onyut et al., 2009). Research has suggested gender differences in terms of how Somalis experience, process, and respond to traumatic stress (Kroll et al., 2010). For example, female Somali refugees are more likely to report mental health problems than male Somali refugees (Feyera et al., 2015; Mölsä et al., 2014) in part due to cultural, social, and gender norms associated with emotional expressions and self-presentation (Kroll et al., 2010). Somali refugee youth have reported using various substances, such as alcohol, drugs, tobacco, and khat (a plant commonly used as a stimulant drug in East Africa), as a coping mechanism; however, research indicates that such substance use can lead to worsened traumatic pain, diminished social functioning, and psychotic symptoms for Somali refugee youth (Im & George, 2021; Odenwald et al., 2005). Dysregulation of destructive emotions, such as anger and aggression, also interferes with refugee youth mental health (Nickerson, 2018; Nickerson et al., 2015; Spiller et al., 2016; Tuomisto & Roche, 2018). In Somali youth, research has indicated that negative emotions, such as anger and aggressive behaviors, following trauma exposure tend to contribute to interpersonal and community violence and fuel the cycle between trauma and violence (Im et al., 2016).

Associations among multiple factors

A substantial body of empirical studies has identified risk factors in refugee youth in general and in Somali refugee youth specifically, but the associations between multiple risk factors are complex and incongruent across studies. For example, several studies have explored acculturative stress, gender discrimination, cultural orientation, and coping style as mediators between refugee trauma exposure and CMDs (Kartal et al., 2018; Kira et al., 2010; Matheson et al., 2008). Another study showed how different types of traumas (e.g. interpersonal- and non-interpersonal-trauma) are associated with CMDs among refugee youth in resettlement (Kim, 2016). A study with young people in South Africa examined how childhood trauma contributes to drug use and the perpetration of interpersonal violence and how such trauma and subsequent life challenges (e.g. food insecurity, disrupted education) directly and indirectly affect depression (Gibbs et al., 2018). One recent study with Somali refugees in the U.S. revealed how acculturation factors may mediate the relationship between refugee trauma and mental health issues (Jorgenson & Nilsson, 2021). These studies suggest pathways and associations among trauma exposure, risk factors, and CMDs, although few have focused specifically on Somali refugee youth in the context of displacement in marginalized communities or LMICs.

Given the magnitude of adversities that refugee youth face during displacement, it is important to untangle how multiple risk factors are intricately linked and contribute to common mental health issues. This study aims to test the pathways from risk factors previously identified as determinants of Somali refugee youth mental health (i.e. trauma exposure, substance use, social functioning, aggression) to symptoms of PTSD, depression, anxiety, and somatic pains. This model examines how substance use as a way of coping with traumatic experiences may affect aggression and social functioning, ultimately influencing mental health in this population. Since there are highly divergent effects of trauma and distinct, gender-based patterns of mental health in the Somali community, we also tested the model with a split-gender sample.

Methods

Participants and procedure

In collaboration with a community-based organization and local clinic in Eastleigh, an urban area in Nairobi, Kenya where many Somali refugees have resettled, we used snowball sampling to recruit Somali refugee youth living in Eastleigh for study participation. This sampling strategy was deemed necessary due to the challenges associated with mobilizing and recruiting refugee participants in urban settings. We included participants aged 15 to 35 years old according to the African Union Commission’s (2006) definition of youth. A local community advisory board and the Institutional Review Board at the authors’ institution approved this research. We collected data in two phases, with the first producing 250 participants in 2013 and the second producing 86 participants later in 2013. After comparing data from the two phases on key study variables revealed adequate phi and Pearson’s correlations, we combined the two phases for a total sample size of 336. After removing 31 cases with missing data, our final sample size was 305.

Measurement

Participants completed a survey, available in both English and Somali, assessing trauma exposure, psychosocial factors, mental health symptoms, and demographic characteristics.

Trauma exposure

In consultation with community partners, the authors compiled a list of 12 trauma experiences that are common in this population (experiencing war, experiencing loss of family members, experiencing domestic violence, living in a refugee camp, experiencing forced migration, experiencing injury from community violence, observation of community violence, being arrested, being kidnapped, experiencing child abuse, experiencing sexual abuse, experiencing a serious accident). For each trauma category, participants indicated whether they had (=1) or had not (=0) experienced that type of trauma. These items were then summed for a theoretical range of 0 to 12. Cronbach’s alpha (α = .780) indicated that this measure had adequate internal reliability.

Psychosocial factors

We assessed substance use with a single item asking participants about their use of substances (i.e. drugs or alcohol) over the past month to reduce stress and bad feelings. We also assessed aggression with a single item asking participants about becoming angry and yelling, hitting, threatening, or destroying things in the past month. We assessed functional impairment by summing two items (α = .735) asking participants about avoiding socialization and feeling unable to fulfill family or community roles. Response options for each of these items ranged from “not at all” (=0) to “almost always” (=4). As adapted from Terheggen et al. (2001), we aimed to help participants understand this Likert-type scale by providing a visual scale showing glasses filled with various amounts of water and images of a monthly calendar with increasing numbers of days marked.

Mental health symptoms

Symptoms of PTSD, depression, and anxiety were assessed using established measures previously used with Somali and refugee populations (Jakobsen et al., 2017; Wind et al., 2017; Yeomans et al., 2010). We used the 17-item PTSD Check List–Civilian Version (PCL-C) to assess symptoms of PTSD and the 25-item Hopkins Symptom Checklist-25 (HSCL-25) to assess symptoms of depression and anxiety. Since there is no established somatization measure validated with this population, through consultation with our community partners, we developed a seven-item measure assessing the presence of the following culturally-relevant somatic symptoms: (1) heavy feelings in the legs and arms, (2) having diarrhea due to stress and bad feelings, (3) having an upset stomach, nausea or bloating, (4) feeling pain in the lower back, (5) having a dry mouth, (6) having cold hands and feet, and (7) being unable to move and becoming like a stone or being frozen.

Response options for each PCL-C, HSCL-25, and somatization item included response options ranging from “not at all” (=0) to “almost always” (=4). As described above, this Likert-type scale was accompanied by a visual scale. Cronbach’s alpha indicated that these measures of PTSD (α = .909), depression (α = .917), anxiety (α = .890), and somatic symptoms (α = .860) had high internal reliability for this sample.

Demographic variables

We also included two demographic control variables. We assessed gender as a dichotomous variable (0 = female, 1 = male) and age as an open-ended continuous variable.

Analytic strategy

We conducted descriptive and bivariate tests followed by three structural equation models estimated using maximum likelihood and 10,000 bootstrapping replications. Each structural equation model assessed paths from trauma exposure to mental health symptoms, through substance use, aggression, and functional impairment (see Supplementary Resource 1). We first conducted this analysis with the full, mixed-gender study sample, while controlling for the effects of age and gender. Then, we assessed gender differences by running one model for male refugee participants and another for female refugee participants, while controlling for the effects of age. Data analyses were conducted in SPSS version 26 and Mplus version 8. With the full, mixed-gender sample (standardized factor loadings ranging from 0.457 to 0.849) and with the female-only sample (standardized factor loadings ranging from 0.360 to 0.909), all factor loadings were significant. With the male-only sample (standardized factor loadings ranging from 0.372 to 0.734), all factor loadings were significant except for the two functional impairment items (see Supplementary Resource 2).

Results

Demographic characteristics

Table 1 shows participant characteristics by gender. The mean age of the sample was 20.04 (SD = 3.01), and there were more female participants (n = 181, 59.3%) than male (n = 124, 40.7%). Male and female participants did not significantly differ on age, trauma exposure, substance use, or aggression, but female participants reported significantly higher functional impairment and more symptoms on all mental health measures.

Table 1.

Participant characteristics.

Variable	M (SD)			Bivariate relationships
Variable	Total (N = 305)	Female (n = 181)	Male (n = 124)	t (df)	p-value
Age (years)	20.04 (3.01)	19.99 (3.11)	20.10 (2.87)	−0.314 (303)	.754
Trauma exposure (0–12)	3.52 (2.86)	3.26 (2.85)	3.91 (2.86)	−1.898 (286)	.059
Substance use (0–4)	0.38 (0.84)	0.42 (0.85)	0.31 (0.81)	1.168 (270.8)	.244
Aggression (0–4)	0.71 (1.17)	0.74 (1.17)	0.67 (1.17)	0.494 (296)	.622
Functional impairment (0–8)	1.75 (2.10)	1.99 (2.24)	1.40 (1.84)	2.478 (287.3)	.014*
Common mental disorders
PTSD symptoms (0–68)	18.24 (13.82)	19.78 (15.01)	16.05 (11.65)	2.411 (292.4)	.017*
Depression symptoms (0–60)	15.85 (12.95)	18.40 (14.09)	12.18 (10.07)	4.422 (292.8)	<.001***
Anxiety symptoms (0–36)	8.86 (7.82)	10.59 (8.39)	6.35 (6.13)	5.037 (295.2)	<.001***
Somatic symptoms (0–28)	5.57 (5.98)	6.88 (6.62)	3.70 (4.30)	5.000 (292.4)	<.001***

Significant at *p < .05. ***p < .001.

Mixed-gender model

The first, mixed-gender model (N = 305) had good fit for the data (χ² = 2035.520, df = 4059, p = 1.000). As shown in Table 2, the model indicated statistically significant direct effects of trauma exposure on substance use (β = .256, p = .003), aggression (β = .272, p = .001), functional impairment (β = .303, p = .002), and symptoms of PTSD (β = .148, p = .036), and anxiety (β = .194, p = .007). Substance use had a direct and positive effect on aggression (β = .315, p < 0.001), functional impairment (β = .294, p < .001), and symptoms of depression (β = .147, p = .013) and somatization (β = .161, p = .021). Aggression and functional impairment had direct and positive effects on symptoms of PTSD (aggression: β = .169, p = .003; functional impairment: β = .549, p < .001), depression (aggression: β = .206, p = .001; functional impairment: β = .522, p < .001), and somatization (aggression: β = .232, p = .001; functional impairment: β = .450, p < .001), while increased functional impairment (β = .501, p < .001) but not aggression (β = .098, p = .146) directly predicted anxiety symptoms.

Table 2.

Structural equation model direct effects.

Dep. variable	Indep. variable	Full sample (N = 305)			Female (N = 181)			Male (N = 124)
Dep. variable	Indep. variable	β	SE	p-value	β	SE	p-value	β	SE	p-value
SU	Gender	−.085	0.099	.146	–	–	–	–	–	–
	Age	−.035	0.016	.535	−.094	0.021	.210	.073	0.024	.387
	Trauma	.256	0.056	.003**	.353	0.088	.004**	.077	0.084	.542
Agg.	Gender	−.029	0.131	.594	–	–	–	–	–	–
	Age	−.038	0.026	.559	.002	0.033	.978	−.094	0.042	.355
	Trauma	.272	0.079	.001**	.306	0.125	.017*	.199	0.127	.130
	SU	.315	0.104	<.001***	.355	0.121	<.001***	.259	0.198	.058
Imp.	Gender	–.145	0.119	.014*	–	–	–	–	–	–
	Age	.096	0.022	.157	.121	0.032	.168	.096	0.029	.382
	Trauma	.303	0.075	.002**	.308	0.125	.020*	.229	0.105	.179
	SU	.294	0.079	<.001***	.342	0.112	<.001***	.213	0.117	.089
PTSD	Gender	−.075	0.069	.127	–	–	–	–	–	–
	Age	.060	0.015	.350	.108	0.021	.187	−.067	0.016	.532
	Trauma	.148	0.038	.036 *	.172	0.072	.107	.167	0.077	.445
	SU	.062	0.040	.209	.072	0.070	.332	.074	0.072	.586
	Agg.	.169	0.034	.003**	.136	0.054	.084	.204	0.044	.091
	Imp.	.549	0.077	<.001***	.496	0.116	.002**	.636	0.172	.035*
Dep.	Gender	−.169	0.083	<.001***	–	–	–	–	–	–
	Age	.034	0.017	.552	.049	0.022	.495	−.008	0.029	.941
	Trauma	.085	0.045	.170	.109	0.074	.244	.080	0.129	.711
	SU	.147	0.064	.013*	.143	0.090	.080	.181	0.157	.299
	Agg.	.206	0.047	.001**	.217	0.074	.019*	.204	0.070	.071
	Imp.	.522	0.089	<.001***	.476	0.119	.001**	.668	0.285	.023*
Anx.	Gender	−.208	0.082	<.001***	–	–	–	–	–	–
	Age	.053	0.017	.367	.057	0.020	.432	.069	0.037	.600
	Trauma	.194	0.048	.007**	.270	0.077	.013**	.084	0.135	.684
	SU	.039	0.059	.497	.022	0.086	.799	.043	0.103	.676
	Agg.	.098	0.049	.146	.171	0.074	.096	.020	0.070	.843
	Imp.	.501	0.092	<.001***	.415	0.122	.011*	.646	0.233	.003**
Som.	Gender	−.233	0.082	<.001***	–	–	–	–	–	–
	Age	.120	0.015	.026*	.114	0.020	.100	.172	0.024	.186
	Trauma	.080	0.040	.198	.092	0.069	.328	.070	0.082	.708
	SU	.161	0.068	.021*	.166	0.090	.057	.191	0.143	.375
	Agg.	.232	0.050	.001**	.238	0.077	.019*	.261	0.078	.123
	Imp.	.450	0.081	<.001***	.457	0.124	.004**	.459	0.185	.077

Note. Agg. = aggression; Imp. = functional impairment; PTSD = PTSD symptoms; Dep. = depression symptoms; Anx. = anxiety symptoms; Som. = somatic symptoms; Trauma = trauma exposure; SU = substance use.

Significant at *p < .05. ** p < .01. *** p < .001.

Table 3 presents the specific indirect effects of this first model, indicating that substance use, aggression, and functional impairment were significant mediators in this model, indirectly affecting relationships between trauma exposure and mental health symptoms. While all hypothesized mediation effects were present for depression and somatic symptom outcomes, substance use did not mediate the relationship between trauma exposure and PTSD symptoms, and several indirect predictors of anxiety symptoms were non-significant.

Table 3.

Structural equation model specific indirect effects (N = 305).

Dependent variable	← Mediator(s)	← Independent variable	β	SE	CI 95%
Dependent variable	← Mediator(s)	← Independent variable	β	SE	Lower limit	Upper limit
Aggression	Substance use	Trauma exposure	.081	0.028	0.028*	0.135*
Impairment^a	Substance use	Trauma exposure	.075	0.022	0.022*	0.108*
PTSD symptoms	Aggression	Trauma exposure	.046	0.011	0.007*	0.049*
	Substance use	Trauma exposure	.016	0.007	−0.006	0.024
	Aggression ← Substance use	Trauma exposure	.014	0.004	0.002*	0.016*
	Impairment	Trauma exposure	.167	0.035	0.032*	0.172*
	Impairment ← Substance use	Trauma exposure	.041	0.009	0.008*	0.043*
	Aggression	Substance use	.053	0.019	0.012*	0.086*
	Impairment	Substance use	.161	0.039	0.066*	0.221*
Depression symptoms	Aggression	Trauma exposure	.056	0.018	0.011*	0.079*
	Substance use	Trauma exposure	.037	0.015	0.003*	0.060*
	Aggression ← Substance use	Trauma exposure	.017	0.006	0.003*	0.025*
	Impairment	Trauma exposure	.158	0.042	0.042*	0.204*
	Impairment ← Substance use	Trauma exposure	.039	0.012	0.010*	0.055*
	Aggression	Substance use	.065	0.026	0.024*	0.127*
	Impairment	Substance use	.153	0.049	0.082*	0.278*
Anxiety symptoms	Aggression	Trauma exposure	.027	0.013	−0.007	0.045
	Substance use	Trauma exposure	.010	0.011	−0.014	0.030
	Aggression ← Substance use	Trauma exposure	.008	0.004	−0.002	0.015
	Impairment	Trauma exposure	.152	0.041	0.036*	0.194*
	Impairment ← Substance use	Trauma exposure	.038	0.011	0.008*	0.052*
	Aggression	Substance use	.031	0.023	−0.011	0.082
	Impairment	Substance use	.147	0.049	0.069*	0.260*
Somatic symptoms	Aggression	Trauma exposure	.063	0.019	0.011*	0.082*
	Substance use	Trauma exposure	.041	0.016	0.003*	0.064*
	Aggression ← Substance use	Trauma exposure	.019	0.006	0.003*	0.025*
	Impairment	Trauma exposure	.136	0.034	0.032*	0.162*
	Impairment ← Substance use	Trauma exposure	.034	0.010	0.007*	0.044*
	Aggression	Substance use	.073	0.026	0.024*	0.126*
	Impairment	Substance use	.132	0.042	0.058*	0.223*

Impairment refers to social functional impairment.

CI indicates significant specific indirect effect.

Modeling gender differences

Table 2 also presents the direct effects of the two split-gender structural equation models. Both the female-only (χ² = 132.049, df = 7463, p = 1.000) and male-only (χ² = 1504.583, df = 4062, p = 1.000) models had good fit for the data. Results showed that in the male sample, only functional impairment had a direct effect on mental health symptoms (PTSD: β = .636, p = .035; depression: β = .668, p = .023; anxiety: β = .646, p = .003; somatic: β = .459, p = .077). However, in the female sample, trauma had a direct and positive effect on substance use (β = .353, p = .004), aggression (β = .306, p = .017), functional impairment (β = .308, p = .020), and anxiety symptoms (β = .270, p = .013). Additionally, in this female sample, substance use had a direct and positive effect on aggression (β = .355, p < .001) and functional impairment (β = .342, p < .001). In the female sample, aggression had a direct and positive effect on symptoms of depression (β = .217, p = .019) and somatization (β = .238, p = .019). Figure 1 shows these significant direct effects from the split-sample models compared to the significant direct effects in the full, mixed-gender sample.

Figure 1.

Significant direct effects in full and split-sample structural equation models.

Table 4 presents the specific indirect effects of the two split-gender models. Results showed substantial gender differences in these indirect effects, with no significant mediation effects in the male sample and many significant mediation effects in the female sample.

Table 4.

Structural equation model specific indirect effects for split-gender samples.

Dep. variable	Mediator(s)	Indep. variable	Female (N = 181)				Male (N = 124)
			β	SE	CI 95%		β	SE	CI 95%
			β	SE	Lower limit	Upper limit	β	SE	Lower limit	Upper limit
Agg.	SU	Trauma	.125	0.047	0.045*	0.225*	.020	0.034	−0.059	0.084
Imp.	SU	Trauma	.121	0.044	0.042*	0.213*	.016	0.019	−0.031	0.047
PTSD	Agg.	Trauma	.042	0.019	−0.003	0.071	.041	0.013	−0.001	0.045
	SU	Trauma	.025	0.019	−0.029	0.055	.006	0.006	−0.007	0.013
	Agg. ← SU	Trauma	.017	0.008	−0.001	0.030	.004	0.003	−0.005	0.008
	Imp.	Trauma	.153	0.061	0.014*	0.248*	.145	0.078	−0.013	0.157
	Imp. ← SU	Trauma	.060	0.019	0.012*	0.083*	.010	0.008	−0.011	0.019
	Agg.	SU	.048	0.029	−0.004	0.107	.053	0.026	−0.002	0.094
	Imp.	SU	.169	0.060	0.060*	0.292*	.136	0.078	−0.013	0.200
Dep.	Agg.	Trauma	.066	0.031	0.005*	0.124*	.041	0.021	−0.002	0.077
	SU	Trauma	.051	0.026	−0.006	0.098	.014	0.019	−0.013	0.053
	Agg. ← SU	Trauma	.027	0.012	0.002*	0.050*	.004	0.005	−0.007	0.013
	Imp.	Trauma	.147	0.064	0.017*	0.263*	.153	0.137	−0.028	0.249
	Imp. ← SU	Trauma	.057	0.021	0.014*	0.094*	.011	0.015	−0.020	0.032
	Agg.	SU	.077	0.042	0.011*	0.174*	.053	0.041	−0.005	0.148
	Imp.	SU	.163	0.065	0.072*	0.325*	.143	0.138	−0.027	0.325
Anx.	Agg.	Trauma	.053	0.027	−0.008	0.097	.004	0.018	−0.037	0.030
	SU	Trauma	.008	0.022	−0.039	0.052	.003	0.011	−0.017	0.018
	Agg. ← SU	Trauma	.021	0.011	−0.003	0.040	.000	0.003	−0.005	0.006
	Imp.	Trauma	.128	0.057	0.010*	0.227*	.148	0.141	−0.030	0.278
	Imp. ← SU	Trauma	.050	0.019	0.008*	0.081*	.011	0.016	−0.022	0.036
	Agg.	SU	.061	0.039	−0.012	0.142	.005	0.030	−0.048	0.075
	Imp.	SU	.142	0.064	0.038*	0.286*	.138	0.112	−0.027	0.337
Som.	Agg.	Trauma	.073	0.033	0.005*	0.134*	.052	0.025	−0.004	0.085
	SU	Trauma	.059	0.027	−0.003	0.104	.015	0.022	−0.009	0.064
	Agg. ← SU	Trauma	.030	0.012	0.003*	0.049*	.005	0.005	−0.006	0.012
	Imp.	Trauma	.141	0.060	0.015*	0.244*	.105	0.072	−0.011	0.145
	Imp. ← SU	Trauma	.055	0.021	0.011*	0.091*	.008	0.008	−0.009	0.017
	Agg.	SU	.085	0.042	0.012*	0.177*	.068	0.037	−0.009	0.130
	Imp.	SU	.156	0.066	0.053*	0.313*	.098	0.075	−0.012	0.168

CI indicates significant specific indirect effect.

Discussion

This study tested structural equation models to examine the relationships among trauma, substance use, functioning, and CMD symptoms among male and female Somali refugee youth in urban Kenya. Functional impairment directly predicted CMD symptoms in both the mixed-gender and split-gender samples. This is consistent with previous studies that emphasize the role of functional impairment in PTSD symptom manifestation (Miró et al., 2020; Norman et al., 2018; Rodriguez et al., 2012). This study extends this finding to other CMD symptoms, revealing that functional impairment also predicts symptoms of depression and anxiety among Somali refugee youth in urban displacement. Aligned with the previous research on gendered patterns in experiencing and communicating mental health issues (Marshall et al., 2016; Young & Chan, 2015), our findings present differential effects of functional impairment on somatization, showing that the significant effect of functional impairment on somatic symptoms is only found among female participants. This may indicate that reporting somatic symptoms is a culturally acceptable way to express trauma-related pains among women (Lehti et al., 2009; Rometsch et al., 2020; Ventevogel & de Jong, 2020), while women and girls likely face a higher vulnerability to mental as well as physical health risks during forced migration (Hollander et al., 2011; Mohwinkel et al., 2018).

Results indicated that trauma exposure had a direct, global impact on Somali refugee youth and yet disproportionately affected functioning as well as CMD symptoms across genders. Trauma exposure directly and indirectly affected CMD symptoms among female participants but neither directly nor indirectly impacted CMD symptoms among males. This may imply a higher vulnerability among female refugees who likely experience greater trauma exposure and gender-specific reactions to trauma and have access to fewer resources for coping, corroborating previous studies on gendered mental health patterns (Kroll et al., 2010; Olff et al., 2007; Renner & Salem, 2009). Female refugees may also be more likely to self-report mental health symptoms than male refugees (Hollander et al., 2011; Mohwinkel et al., 2018; Pottie et al., 2005). Gender differences were notable in the relationship between functional impairment and somatization, which may be explained by the disproportionate pervasiveness of somatoform pains among women (Hessel et al., 2002; Hiller et al., 2006; Jacobi et al., 2004). Additionally, Somali girls commonly face female genital mutilation or cutting (United Nations International Children’s Emergency Fund, 2016), which is believed to contribute to somatic symptoms that likely reflect aggregated physical and mental health risks (Im et al., 2020; Mulongo et al., 2014; Pereda et al., 2012).

As hypothesized, substance use was a key predictor of functional impairment, aggression, and CMDs, although there were differences in these relationships based on gender. Female Somali youth who reported substance use presented with higher levels of aggression and functional impairment that led to negative mental health outcomes. Previous research has shown mixed results regarding the effect of gender on pathways from substance use to mental health. Some research (Schwinn et al., 2010) has shown little effects of gender on the relationship between substance use and mental health, while our findings corroborate other studies showing the effect of gender on this relationship (Saban et al., 2010; Schiff & Fang, 2014). Given the cultural and social norms in the Somali community, where substance use is often considered more socially acceptable for men but highly stigmatized for women (Osman & Söderbäck, 2011; Salama et al., 2018), Somali men may use substances more recreationally and casually, while tabooed use of substances among Somali women may be associated with an increased risk of substance use as self-medication, deviant behaviors and delinquency, and social marginalization (Authors, 2021; Gunn et al., 2018; Neupane & Bramness, 2014). The current study adds to this growing body of literature, implying that substance use is an indicator of higher risk for CMDs and other associated functional issues for Somali refugee women. A more nuanced approach is necessary for Somali refugee men despite the overall harmful effects of substances on mental health.

Implications

This study highlights the role of social functioning in addressing trauma-related mental health symptoms in refugee youth displaced in urban, low-resource settings. Recent studies have focused on the improvement of individual functioning through transdiagnostic psychological interventions (e.g. Problem Management Plus, Self-Help Plus). Although these scaleable interventions have made significant contributions, many are designed as gender-neutral or are aimed at women or victims of gender-based violence but are not necessarily informed by different patterns of social functioning and their mental health consequences for both genders (Akhtar et al., 2020; Dawson et al., 2015; Heim et al., 2019; Tol et al., 2020). To effectively intervene to address reduced social functioning, this study points to the need for future interventions to be informed by the divergent effects of cumulative traumas and substance use across genders in order to take a culturally nuanced and gender-sensitive approach to mental health care. Given the inequitable access to services and community resources among refugee women in low-income countries (Kohrt et al., 2018), Somali refugee women are likely more vulnerable to harmful effects of substances as well as trauma exposure, and therefore, trauma-informed prevention that incorporates social protection is necessary. For male Somali refugee youth, experiences of trauma and substance use alone may not significantly predict CMD symptoms via functional impairment or aggression, which implies that other psychosocial factors may buffer or exacerbate mental health issues as well as social functioning. Future studies could test pathways through variables such as employment, social discrimination, and other sources of distress to better understand risk and protection from mental health issues. Given the impeded social support systems during displacement, interventions that strengthen family and community support systems, as well as social and economic empowerment and protection, are critical to the mental health of urban refugee youth (Lahiri et al., 2017; Logie et al., 2020; Reed et al., 2012; Torre, 2020). Given the differential pathways to CMD symptoms, future research may consider more gender-responsive and locally grounded questions that consider sociocultural and structural challenges faced by urban refugees (Freedman, 2010). In order to further understand mental health issues in both genders, daily challenges and structural issues commonly faced by urban refugees in LMICs need to be considered in future studies, such as legal protection or documentation, livelihoods and poverty, education, social discrimination, community infrastructures, and basic social services and healthcare access (Im et al., 2017).

Limitations

These findings must be interpreted with the consideration of several study limitations. First, participants were recruited using snowball sampling since the target population is hard to reach due to their highly mobile and unstable status as urban refugees (Pavanello et al., 2010). Although this sampling strategy was unavoidable due to the lack of a complete or known sampling frame (Kim et al., 2019; Spring et al., 2003), it limits the representativeness of the study sample and the generalizability of these findings. Second, this study used a self-report survey design, in which some variables relied on single items or measures that have yet to be culturally validated (e.g. substance use, aggression, and social functioning). The questions adopted in this study allowed us to capture important information on constructs that currently lack culturally validated measures; however, it also decreases confidence in the accuracy of these findings. This study provides important information about relationships between study variables, but its cross-sectional design precludes causal inferences. Future longitudinal studies could provide causal evidence about these study variables by investigating their time order. Finally, this model does not involve sociocultural and structural factors, such as poverty, documentation or refugee status, social discrimination, and acculturative stress during displacement, which might contribute significantly to mental health outcomes as well as social functioning. In fact, several studies have revealed the mediating role of discrimination in the relationships between refugee trauma and mental health (Kira et al., 2010; Oppedal & Idsoe, 2015), while others have emphasized the importance of food security and community insecurity, as well as social support, in depressive symptoms among displaced refugees (Logie et al., 2020; Mugisha et al., 2015).

Conclusion

Female Somali refugee youth are likely more susceptible to direct harmful effects of trauma exposures and substance use, whereas male Somali refugee youth are afflicted by impeded social functioning. This is the first study examining how common adverse factors relate to low social functioning and mental health outcomes among Somali refugee youth displaced in urban, low-resource settings. Specifically, this study highlights how trauma-related CMD symptoms are differently manifested through substance use and social functioning based on gender. It sheds light on the need for gender-sensitive and culturally nuanced approaches to mental health care for this population.

Supplemental Material

sj-pdf-1-isp-10.1177_00207640211037726 – Supplemental material for Trauma exposure, social functioning, and common mental health disorders in Somali refugee male and female youth: An SEM analysis

Supplemental material, sj-pdf-1-isp-10.1177_00207640211037726 for Trauma exposure, social functioning, and common mental health disorders in Somali refugee male and female youth: An SEM analysis by Hyojin Im and Laura ET Swan in International Journal of Social Psychiatry

Footnotes

Acknowledgements

The authors wish to thank Somali refugee community leaders and study participants in Eastleigh, Kenya. This study is indebted to Tawakal Medical Centre (TMC).

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical statement

This study was approved by IRB approval from the authors’ institution. In addition, the research protocol and materials were reviewed and approved by a locally formed community ethics committee that comprises of Somali community leaders and medical professionals. All procedures performed in this study were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The first half of the data collection was supported by the Kenya Transitional Initiative, USAID (CHXEAS053).

ORCID iD

Hyojin Im

Supplemental material

Supplemental material for this article is available online.

References

African Union Commission. (2006). African youth charter. Retrieved from https://au.int/en/treaties/african-youth-charter (accessed 20 July 2019).

Ahmad

Othman

Lou

(2020). Posttraumatic stress disorder, social support and coping among Afghan refugees in Canada. Community Mental Health Journal, 56, 597–605. https://doi.org/10.1007/s10597-019-00518-1

Akhtar

Giardinelli

Bawaneh

Awwad

Naser

Whitney

Jordans

M. J.

Sijbrandij

Bryant

R. A.

(2020). Group problem management plus (gPM+) in the treatment of common mental disorders in Syrian refugees in a Jordanian camp: Study protocol for a randomized controlled trial. BMC Public Health, 20(1), 1–8. https://doi.org/10.1186/s12889-020-08463-5

Bielas

Barra

Skrivanek

Aebi

Steinhausen

H. C.

Bessler

Plattner

(2016). The associations of cumulative adverse childhood experiences and irritability with mental disorders in detained male adolescent offenders. Child and Adolescent Psychiatry and Mental Health, 10, 34. https://doi.org/10.1186/s13034-016-0122-7

Blackmore

Boyle

J. A.

Fazel

Ranasinha

Gray

K. M.

Fitzgerald

Misso

Gibson-Helm

(2020). The prevalence of mental illness in refugees and asylum seekers: A systematic review and meta-analysis. PLoS Medicine, 17(9), e1003337. https://doi.org/10.1371/journal.pmed.1003337

Dawson

K. S.

Bryant

R. A.

Harper

Kuowei Tay

Rahman

Schafer

van Ommeren

(2015). Problem management plus (PM+): A WHO transdiagnostic psychological intervention for common mental health problems. World Psychiatry, 14(3), 354–357. https://doi.org/10.1002/wps.20255

de Anstiss

Ziaian

. (2010). Mental health help-seeking and refugee adolescents: Qualitative findings from a mixed-methods investigation. Australian Psychologist, 45(1), 29–37. https://doi.org/10.1080/00050060903262387

de Jong

van der Kam

Swarthout

Ford

Mills

Yun

Kleber

R. J

. (2011). Exposure to violence and PTSD symptoms among Somali women. Journal of Traumatic Stress, 24(6), 628–634. https://doi.org/10.1002/jts.20694

Ellis

B. H.

MacDonald

H. Z.

Klunk-Gillis

Lincoln

Strunin

Cabral

H. J.

(2010). Discrimination and mental health among Somali refugee adolescents: The role of acculturation and gender. American Journal of Orthopsychiatry, 80(4), 564–575. https://doi.org/10.1111/j.1939-0025.2010.01061.x

10.

Ertl

Saile

Neuner

Catani

(2016). Drinking to ease the burden: A cross-sectional study on trauma, alcohol abuse and psychopathology in a post-conflict context. BMC Psychiatry, 16(1), 202–213. https://doi.org/10.1186/s12888-016-0905-7

11.

Fazel

Wheeler

Danesh

(2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet, 365(9467), 1309–1314. https://doi.org/10.1016/s0140-6736(05)61027-6

12.

Feyera

Mihretie

Bedaso

Gedle

Kumera

(2015). Prevalence of depression and associated factors among Somali refugee at Melkadida Camp, Southeast Ethiopia: A cross-sectional study. BMC Psychiatry, 15, 1–7. https://doi.org/10.1186/s12888-015-0539-1

13.

Freedman

(2010). Mainstreaming gender in refugee protection. Cambridge Review of International Affairs, 23(4), 589–607. https://doi.org/10.1080/09557571.2010.523820

14.

Frounfelker

R. L.

Miconi

Farrar

Brooks

M. A.

Rousseau

Betancourt

T. S

. (2020). Mental health of refugee children and youth: Epidemiology, interventions, and future directions. Annual Review of Public Health, 41(1), 159–176. https://doi.org/10.1146/annurev-publhealth-040119-094230

15.

Giacco

Laxhman

Priebe

(2018). Prevalence of and risk factors for mental disorders in refugees. Seminars in Cell and Developmental Biology, 77, 144–152. https://doi.org/10.1016/j.semcdb.2017.11.030

16.

Gibbs

Jewkes

Willan

Washington

(2018). Associations between poverty, mental health and substance use, gender power, and intimate partner violence amongst young (18-30) women and men in urban informal settlements in South Africa: A cross-sectional study and structural equation model. PLoS One, 13(10), e0204956. https://doi.org/10.1371/journal.pone.0204956

17.

Gunn

A. J.

Sacks

T. K.

Jemal

(2018). “That’s not me anymore”: Resistance strategies for managing intersectional stigmas for women with substance use and incarceration histories. Qualitative Social Work, 17(4), 490–508. https://doi.org/10.1177/1473325016680282

18.

Heim

Shehadeh

M. H.

Van’t Hof

Carswell

(2019). Cultural adaptation of scalable interventions. In Maercker

Heim

Kirmayer

L. J.

(Eds.), Cultural clinical psychology and PTSD (pp. 201–218). Hogrefe Publishing.

19.

Hessel

Geyer

Schumacher

Brähler

(2002). Somatoform complaints in the German population. Zeitschrift Fur Psychosomatische Medizin Und Psychotherapie, 48(1), 38–58. https://doi.org/10.13109/zptm.2002.48.1.38

20.

Hiller

Rief

Brähler

(2006). Somatization in the population: From mild bodily misperceptions to disabling symptoms. Social Psychiatry and Psychiatric Epidemiology, 41(9), 704–712. https://doi.org/10.1007/s00127-006-0082-y

21.

Hinton

D. E.

Lewis-Fernández

(2011). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety, 28(9), 783–801. https://doi.org/10.1002/da.20753

22.

Hollander

A. C.

Bruce

Burström

Ekblad

(2011). Gender-related mental health differences between refugees and non-refugee immigrants: A cross-sectional register-based study. BMC Public Health, 11(1), 1–8. https://doi.org/10.1186/1471-2458-11-180

23.

Horyniak

Melo

J. S.

Farrell

R. M.

Ojeda

V. D.

Strathdee

S. A.

(2016). Epidemiology of substance use among forced migrants: A global systematic review. PLoS One, 11(7), e0159134. https://doi.org/10.1371/journal.pone.0159134

24.

George

(2021). “It hurts so much to live for nothing”: Lived experiences of substance use among refugee youth in displacement. International Journal of Mental Health and Addiction. Advance online publication. https://doi.org/10.1007/s11469-020-00472-0

25.

Caudill

Ferguson

A. B.

(2016). From victim to perpetrator of trauma: Lived experiences of gang-involved urban refugee youth in Kenya. Journal of Aggression, Maltreatment & Trauma, 25(7), 753–771. https://doi.org/10.1080/10926771.2016.1194939

26.

Ferguson

A. B.

Warsame

A. H.

Isse

M. M.

(2017). Mental health risks and stressors faced by urban refugees: Perceived impacts of war and community adversities among Somali refugees in Nairobi. International Journal of Social Psychiatry, 63(8), 686–693. https://doi.org/10.1177/0020764017728966

27.

Swan

L. E.

Heaton

(2020). Polyvictimization and mental health consequences of female genital mutilation/circumcision (FGM/C) among Somali refugees in Kenya. Women & Health, 60(6), 636–651. https://doi.org/10.1080/03630242.2019.1689543

28.

Jacobi

Wittchen

H. U.

Holting

Höfler

Pfister

Müller

Lieb

(2004). Prevalence, co-morbidity and correlates of mental disorders in the general population: Results from the German Health Interview and Examination Survey (GHS). Psychological Medicine, 34(4), 597–611. https://doi.org/10.1017/s0033291703001399

29.

Jakobsen

Meyer DeMott

M. A.

Heir

(2017). Validity of screening for psychiatric disorders in unaccompanied minor asylum seekers: Use of computer-based assessment. Transcultural Psychiatry, 54(5–6), 611–625. https://doi.org/10.1177/1363461517722868

30.

Jensen

T. K.

Fjermestad

K. W.

Granly

Wilhelmsen

N. H.

(2015). Stressful life experiences and mental health problems among unaccompanied asylum-seeking children. Clinical Child Psychology and Psychiatry, 20(1), 106–116. https://doi.org/10.1177/1359104513499356

31.

Jorgenson

K. C.

Nilsson

J. E.

(2021). The relationship among trauma, acculturation, and mental health symptoms in Somali refugees. The Counseling Psychologist, 49(2), 196–232. https://doi.org/10.1177/0011000020968548

32.

Kartal

Alkemade

Eisenbruch

Kissane

(2018). Traumatic exposure, acculturative stress and cultural orientation: The influence on PTSD, depressive and anxiety symptoms among refugees. Social Psychiatry and Psychiatric Epidemiology, 53, 931–941. https://doi.org/10.1007/s00127-018-1532-z

33.

Kim

ElRayes

Anthony

R. S.

Dombrowski

Watanabe-Galloway

(2019). A review of health survey research for people with refugee background resettled from Africa: Research gaps and methodological issues. Journal of Racial and Ethnic Health Disparities, 6(1), 160–181. https://doi.org/10.1007/s40615-018-0511-0

34.

Kim

Y. J.

(2016). Posttraumatic stress disorder as a mediator between trauma exposure and comorbid mental health conditions in North Korean refugee youth resettled in South Korea. Journal of Interpersonal Violence, 31(3), 425–443. https://doi.org/10.1177/0886260514555864

35.

Kira

I. A.

Smith

Lewandowski

Templin

(2010). The effects of gender discrimination on refugee torture survivors: A cross-cultural traumatology perspective. Journal of the American Psychiatric Nurses Association, 16(5), 299–306. https://doi.org/10.1177/1078390310384401

36.

Kohrt

B. A.

Asher

Bhardwaj

Fazel

Jordans

M. J. D.

Mutamba

B. B.

Nadkarni

Pedersen

G. A.

Singla

D. R.

Patel

(2018). The role of communities in mental health care in low- and middle-income countries: A meta-review of components and competencies. International Journal of Environmental Research and Public Health, 15(6), 1279. https://doi.org/10.3390/ijerph15061279

37.

Kroll

Yusuf

A. I.

Fujiwara

(2010). Psychoses, PTSD, and depression in Somali refugees in Minnesota. Social Psychiatry and Psychiatric Epidemiology, 46(6), 481–493. https://doi.org/10.1007/s00127-010-0216-0

38.

Lahiri

van Ommeren

Roberts

(2017). The influence of humanitarian crises on social functioning among civilians in low- and middle-income countries: A systematic review. Global Public Health, 12(12), 1461–1478. https://doi.org/10.1080/17441692.2016.1154585

39.

Lehti

Hammarström

Mattsson

(2009). Recognition of depression in people of different cultures: A qualitative study. BMC Family Practice, 10(1), 1–9. https://doi.org/10.1186/1471-2296-10-53

40.

Lockwood

Forbes

(2014). Posttraumatic stress disorder and comorbidity: Untangling the Gordian knot. Psychological Injury and Law, 7, 108–121. https://doi.org/10.1007/s12207-014-9189-8

41.

Logie

C. H.

Okumu

Mwima

Hakiza

Chemutai

Kyambadde

(2020). Contextual factors associated with depression among urban refugee and displaced youth in Kampala, Uganda: Findings from a cross-sectional study. Conflict and Health, 14, 1–13. https://doi.org/10.1186/s13031-020-00289-7

42.

Marshall

E. A.

Butler

Roche

Cumming

Taknint

J. T.

(2016). Refugee youth: A review of mental health counselling issues and practices. Canadian Psychology/Psychologie Canadienne, 57(4), 308–319. https://doi.org/10.1037/cap0000068

43.

Matheson

Jorden

Anisman

(2008). Relations between trauma experiences and psychological, physical and neuroendocrine functioning among Somali refugees: Mediating role of coping with acculturation stressors. Journal of Immigrant and Minority Health, 10(4), 291–304. https://doi.org/10.1007/s10903-007-9086-2

44.

McGregor

L. S.

Melvin

G. A.

Newman

L. K.

(2015). Familial separations, coping styles, and PTSD symptomatology in resettled refugee youth. The Journal of Nervous and Mental Disease, 203(6), 431–438. https://doi.org/10.1097/NMD.0000000000000312

45.

Miró

Martínez

M. P.

Sánchez

A. I.

Cáliz

(2020). Clinical manifestations of trauma exposure in fibromyalgia: The role of anxiety in the association between posttraumatic stress symptoms and fibromyalgia status. Journal of Traumatic Stress, 33(6), 1082–1092. https://doi.org/10.1002/jts.22550

46.

Mohwinkel

L. M.

Nowak

A. C.

Kasper

Razum

(2018). Gender differences in the mental health of unaccompanied refugee minors in Europe: A systematic review. BMJ Open, 8(7), e022389. https://doi.org/10.1136/bmjopen-2018-022389

47.

Mölsä

Punamäki

R. L.

Saarni

S. I.

Tiilikainen

Kuittinen

Honkasalo

M. L.

(2014). Mental and somatic health and pre- and post-migration factors among older Somali refugees in Finland. Transcultural Psychiatry, 51(4), 499–525. https://doi.org/10.1177/1363461514526630

48.

Mugisha

Muyinda

Wandiembe

Kinyanda

(2015). Prevalence and factors associated with posttraumatic stress disorder seven years after the conflict in three districts in northern Uganda (The Wayo-Nero Study). BMC Psychiatry, 15(1), 1–12. https://doi.org/10.1186/s12888-015-0551-5

49.

Mulongo

Hollins Martin

McAndrew

(2014). The psychological impact of female genital mutilation/cutting (FGM/C) on Girls/women’s mental health: A narrative literature review. Journal of Reproductive and Infant Psychology, 32(5), 469–485. https://doi.org/10.1080/02646838.2014.949641

50.

Neupane

S. P.

Bramness

J. G.

(2014). Who seeks treatment for alcohol problems? Demography and alcohol-use characteristics of patients in taboo and non-taboo drinking groups attending professional alcohol services in Nepal. Asian Journal of Psychiatry, 12, 82–87. https://doi.org/10.1016/j.ajp.2014.06.017

51.

Newnham

E. A.

Kashyap

Tearne

Fazel

(2018). Child mental health in the context of war: An overview of risk factors and interventions for refugee and war-affected youth. In Morina

Nickerson

(Eds.), Mental health of refugee and conflict-affected populations (pp. 37–63). Springer.

52.

Nickerson

(2018). Pathways to recovery: Psychological mechanisms underlying refugee mental health. In Morina

Nickerson

(Eds.), Mental health of refugee and conflict-affected populations (pp. 91–109). Springer.

53.

Nickerson

Bryant

R. A.

Schnyder

Schick

Mueller

Morina

(2015). Emotion dysregulation mediates the relationship between trauma exposure, post-migration living difficulties and psychological outcomes in traumatized refugees. Journal of Affective Disorders, 173, 185–192. https://doi.org/10.1016/j.jad.2014.10.043

54.

Norman

S. B.

Haller

Kim

H. M.

Allard

C. B.

Porter

K. E.

Stein

M. B.

Venners

M. R.

Authier

C. C.

Rauch

S. A. M.

; Progress Team. (2018). Trauma related guilt cognitions partially mediate the relationship between PTSD symptom severity and functioning among returning combat veterans. Journal of Psychiatric Research, 100, 56–62. https://doi.org/10.1016/j.jpsychires.2018.02.003

55.

Odenwald

Neuner

Schauer

Elbert

Catani

Lingenfelder

Hinkel

Häfner

Rockstroh

(2005). Khat use as risk factor for psychotic disorders: A cross-sectional and case-control study in Somalia. BMC Medicine, 3(5), 5–10. http://www.biomedcentral.com/1741-7015/3/5

56.

Olff

Langeland

Draijer

Gersons

B. P.

(2007). Gender differences in posttraumatic stress disorder. Psychological Bulletin, 133(2), 183–204. https://doi.org/10.1037/0033-2909.133.2.183

57.

Onyut

L. P.

Neuner

Ertl

Schauer

Odenwald

Elbert

(2009). Trauma, poverty and mental health among Somali and Rwandese refugees living in an African refugee settlement: An epidemiological study. Conflict and Health, 3(1), 1–16. https://doi.org/10.1186/1752-1505-3-6

58.

Oppedal

Idsoe

(2015). The role of social support in the acculturation and mental health of unaccompanied minor asylum seekers. Scandinavian Journal of Psychology, 56(2), 203–211. https://doi.org/10.1111/sjop.12194

59.

Osman

F. A.

Söderbäck

(2011). Perceptions of the use of khat among Somali immigrants living in Swedish society. Scandinavian Journal of Public Health, 39, 212–219. https://doi.org/10.1177/1403494810384908

60.

Patel

Flisher

A. J.

Nikapota

Malhotra

(2008). Promoting child and adolescent mental health in low and middle income countries. Journal of Child Psychology and Psychiatry, 49(3), 313–334. https://doi.org/10.1111/j.1469-7610.2007.01824.x

61.

Pavanello

Elhawary

Pantuliano

(2010). Hidden and exposed: Urban refugees in Nairobi, Kenya. Overseas Development Institute.

62.

Pereda

Arch

Pérez-González

(2012). A case study perspective on psychological outcomes after female genital mutilation. Journal of Obstetrics and Gynaecology, 32(6), 560–565. https://doi.org/10.3109/01443615.2012.689893

63.

Pieloch

K. A.

McCullough

M. B.

Marks

A. K.

(2016). Resilience of children with refugee statuses: A research review. Canadian Psychology, 57(4), 330–339. https://doi.org/10.1037/cap0000073

64.

Porter

Haslam

(2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: A meta-analysis. The Journal of the American Medical Association, 294(5), 602–612. https://doi.org/10.1001/jama.294.5.602

65.

Posselt

Procter

Galletly

Crespigny

(2015). Aetiology of coexisting mental health and alcohol and other drug disorders: Perspectives of refugee youth and service providers. Australian Psychologist, 50(2), 130–140. https://doi.org/10.1111/ap.12096

66.

Pottie

Brown

J. B.

Dunn

(2005). The resettlement of Central American men in Canada: From emotional distress to successful integration. Refuge, 22(2), 101–111. https://doi.org/10.25071/1920-7336.21335

67.

Reed

R. V.

Fazel

Jones

Panter-Brick

Stein

(2012). Mental health of displaced and refugee children resettled in low-income and middle-income countries: Risk and protective factors. The Lancet, 379(9812), 250–265. https://doi.org/10.1016/s0140-6736(11)60050-0

68.

Renner

Salem

(2009). Post-traumatic stress in asylum seekers and refugees from Chechnya, Afghanistan, and West Africa: Gender differences in symptomatology and coping. International Journal of Social Psychiatry, 55(2), 99–108. https://doi.org/10.1177/0020764008092341

69.

Roberts

Browne

(2011). A systematic review of factors influencing the psychological health of conflict-affected populations in low- and middle-income countries. Global Public Health, 6(8), 814–829. https://doi.org/10.1080/17441692.2010.511625

70.

Rodriguez

Holowka

D. W.

Marx

B. P.

(2012). Assessment of posttraumatic stress disorder-related functional impairment: A review. Journal of Rehabilitation Research and Development, 49(5), 649. https://doi.org/10.1682/jrrd.2011.09.0162

71.

Rometsch

Denkinger

J. K.

Engelhardt

Windthorst

Graf

Gibbons

Pham

Zipfel

Junne

(2020). Pain, somatic complaints, and subjective concepts of illness in traumatized female refugees who experienced extreme violence by the “Islamic State” (IS). Journal of Psychosomatic Research, 130, 109931. https://doi.org/10.1016/j.jpsychores.2020.109931

72.

Saban

Flisher

A. J.

Distiller

(2010). Association between psychopathology and substance use among school-going adolescents in Cape Town, South Africa. Journal of Psychoactive Drugs, 42(4), 467–476. https://doi.org/10.1080/02791072.2010.10400709

73.

Salama

Niemelä

Suvisaari

Laatikainen

Koponen

Castaneda

A. E.

(2018). The prevalence of substance use among Russian, Somali and Kurdish migrants in Finland: A population-based study. BMC Public Health, 18, 651. https://doi.org/10.1186/s12889-018-5564-9

74.

Scharpf

Kaltenbach

Nickerson

Hecker

(2020). A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents. Clinical Psychology Review, 83, 101930. https://doi.org/10.1016/j.cpr.2020.101930

75.

Schiff

Fang

(2014). Adolescent substance use in Israel: The roles of exposure to political traumas and posttraumatic stress symptoms. Psychology of Addictive Behaviors, 28(2), 453–463. https://doi.org/10.1037/a0035603

76.

Schubert

C. C.

Punamäki

R. L.

(2011). Mental health among torture survivors: Cultural background, refugee status and gender. Nordic Journal of Psychiatry, 65(3), 175–182. https://doi.org/10.3109/08039488.2010.514943

77.

Schwinn

T. M.

Schinke

S. P.

Trent

D. N.

(2010). Substance use among late adolescent urban youths: Mental health and gender influences. Addictive Behaviors, 35(1), 30–34. https://doi.org/10.1016/j.addbeh.2009.08.005

78.

Sherin

J. E.

Nemeroff

C. B.

(2011). Post-traumatic stress disorder: The neurobiological impact of psychological trauma. Dialogues in Clinical Neuroscience, 13(3), 263–278. https://doi.org/10.31887/dcns.2011.13.2/jsherin

79.

Spiller

T. R.

Schick

Schnyder

Bryant

R. A.

Nickerson

Morina

(2016). Somatisation and anger are associated with symptom severity of posttraumatic stress disorder in severely traumatised refugees and asylum seekers. Swiss Medical Weekly, 146, w14311. https://doi.org/10.4414/smw.2016.14311

80.

Spring

Westermeyer

Halcon

Savik

Robertson

Johnson

D. R.

Butcher

J. N.

Jaranson

(2003). Sampling in difficult to access refugee and immigrant communities. The Journal of Nervous and Mental Disease, 191(12), 813–819. https://doi.org/10.1097/01.nmd.0000100925.24561.8f

81.

Terheggen

M. A.

Stroebe

M. S.

Kleber

R. J.

(2001). Western conceptualizations and eastern experience: A cross-cultural study of traumatic stress reactions among Tibetan refugees in India. Journal of Traumatic Stress, 14, 391–403. https://doi.org/10.1023/a:1011177204593

82.

Tol

W. A.

Komproe

I. H.

Jordans

M. J.

Gross

A. L.

Susanty

Macy

R. D.

de Jong

J. T.

(2010). Mediators and moderators of a psychosocial intervention for children affected by political violence. Journal of Consulting and Clinical Psychology, 78(6), 818–828. https://doi.org/10.1037/a0021348

83.

Tol

W. A.

Leku

M. R.

Lakin

D. P.

Carswell

Augustinavicius

Adaku

T. M.

Brown

F. L.

Bryant

R. A.

Garcia-Moreno

Musci

R. J.

Ventevogel

White

R. G.

van Ommeren

(2020). Guided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: A cluster randomised trial. The Lancet Global Health, 8(2), e254–e263. https://doi.org/10.1016/S2214-109X(19)30504-2

84.

Torre

(2020). Self-help or silenced voices? An ethnographically informed warning. The Lancet Global Health, 8(5), e646. https://doi.org/10.1016/S2214-109X(20)30106-6

85.

Tuomisto

M. T.

Roche

J. E.

(2018). Beyond PTSD and fear-based conditioning: Anger-related responses following experiences of forced migration: A systematic review. Frontiers in Psychology, 9, 2592. https://doi.org/10.3389/fpsyg.2018.02592

86.

United Nations High Commissioner for Refugees. (2020a). Global trends: Forced displacement in 2019. Retrieved from https://www.unhcr.org/5ee200e37.pdf (accessed 1 December 2020).

87.

United Nations High Commissioner for Refugees. (2020b). Somalia refugee crisis explained. Retrieved from https://www.unrefugees.org/news/somalia-refugee-crisis-explained/#WherehaveSomalirefugeesfledto? (accessed 1 December 2020).

88.

United Nations International Children’s Emergency Fund. (2016). Female genital mutilation/cutting: A global concern. Retrieved from https://www.unicef.org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdf (accessed 20 July 2019).

89.

Ventevogel

de Jong

J. T.

(2020). Depression and anxiety in refugee children. In Song

S. J.

Ventevogel

(Eds.), Child, adolescent and family refugee mental health (pp. 165–178). Springer.

90.

Vossoughi

Jackson

Gusler

Stone

(2018). Mental health outcomes for youth living in refugee camps: A review. Trauma Violence & Abuse, 19(5), 528–542. https://doi.org/10.1177/1524838016673602

91.

Wind

T. R.

van der Aa

Knipscheer

de la Rie

(2017). The assessment of psychopathology among traumatized refugees: Measurement invariance of the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25 across five linguistic groups. European Journal of Psychotraumatology, 8, 1–11. https://doi.org/10.1080/20008198.2017.1321357

92.

Yeomans

P. D.

Forman

E. M.

Herbert

J. D.

Yuen

(2010). A randomized trial of a reconciliation workshop with and without PTSD psychoeducation in Burundian sample. Journal of Traumatic Stress, 23(3), 305–312. https://doi.org/10.1002/jts.20531

93.

Young

M. Y.

Chan

K. J.

(2015). The psychological experience of refugees: A gender and cultural analysis. In Safdar

Kosakowska-Berezecka

(Eds.), Psychology of gender through the lens of culture: Theories and applications (pp. 17–36). Springer.

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